The Loudest Patient Isn't Always the Most Important

One of the hardest things to learn in emergency nursing isn't how to do more.

It's how to decide what doesn't need to be done yet.

Emergency departments are full of competing demands.

A patient wants analgesia.
Someone is asking when they can go home.
A doctor needs an IV inserted.
The phone is ringing.
An ambulance is arriving.
A colleague needs help.
A medication needs preparing.
Someone's observations have changed.

And somehow, you're expected to work out what matters most.

The problem is that the thing demanding your attention isn't always the thing that needs it most.

The loudest problem can be a distraction

I remember working through a multiple-patient trauma situation where several patients arrived with significant injuries.

There was pain, distress, uncertainty and plenty of noise.

One patient was particularly vocal. They were distressed, wanted to know what was happening and understandably wanted their pain treated.

Another patient was quieter.

But their injuries carried a much greater immediate risk.

The decision about where our resources needed to go was relatively straightforward.

The distressed patient needed care.

But they could safely wait a little longer.

The other patient couldn't.

That distinction is easy to see when the difference is dramatic.

Emergency nursing becomes much harder when it isn't.

Because sometimes you have several patients who genuinely need something.

The question becomes:

Who needs it now?

And perhaps more importantly:

What is safer to wait?

Urgency isn't the same as importance

One of the traps of working in a busy emergency department is that activity can start to feel like urgency.

The patient who keeps calling you feels urgent.

The task you've already started feels urgent.

The doctor asking you for something feels urgent.

The phone ringing feels urgent.

The person standing directly in front of you feels urgent.

But urgency and importance aren't necessarily the same thing.

Someone can be very demanding without being clinically unstable.

A task can be important without needing to happen immediately.

And a patient who is saying very little can be the person whose condition needs your attention most.

This is one of the reasons I think experienced emergency nurses sometimes look like they're doing less than everyone else.

They're not necessarily doing less.

They're filtering.

They're constantly deciding:

What actually needs me right now?

What can safely wait?

When I have several competing things happening, I tend to mentally sort them into a few simple categories.

Some things are just administration.

The phone call.

The roster problem.

The paperwork.

The non-urgent request that someone would really like sorted.

Then there are things that matter clinically but can wait.

A medication might be important but still be safe to give in another hour.

An assessment might need completing but not necessarily in the next five minutes.

Another patient might need attention but be stable enough for someone else to manage.

Then there are the things that need you now.

The deteriorating patient.

The compromised airway.

The patient whose condition is changing.

The IV access that needs to be established before the situation becomes more difficult.

The incoming patient who may require immediate resources.

The difficulty is that these categories aren't fixed.

They change.

The thing that could wait ten minutes ago might not be able to wait now.

That's why prioritisation isn't a checklist.

It's a continuous process.

Ask yourself what happens if you don't do it

One of the simplest questions I use when everything starts competing for my attention is:

What happens if I don't deal with this now?

It's a surprisingly useful question.

What happens if I don't answer the phone?

Probably nothing.

What happens if I don't fix that administrative problem?

It can wait.

What happens if I don't give this medication for another hour?

Maybe nothing significant.

What happens if I don't reassess the patient whose breathing has changed?

That could be very different.

What happens if I don't establish IV access on the patient who is becoming increasingly unstable?

I may make the next ten minutes much harder.

What happens if I don't address the increasingly agitated patient?

Maybe nothing.

Or perhaps they become a much bigger problem in ten minutes and suddenly require far more resources.

The point isn't to predict the future perfectly.

You can't.

It's to think about consequences.

You're asking:

Which problem becomes dangerous if I leave it?

That's a very different question from:

Which problem is annoying me the most?

Don't diagnose too early

There is another part of prioritisation that I think is easy to overlook.

Sometimes the safest thing you can do is avoid deciding too early what you think is wrong.

It sounds counterintuitive.

Surely clinical reasoning is about working out the diagnosis?

Eventually, yes.

But early in an emergency assessment, I prefer to keep several possibilities open.

If I decide too quickly that a patient has a particular problem, I can start looking for information that confirms what I've already decided.

That's confirmation bias.

It can also change the way I prioritise my assessment.

Instead of asking:

"What is happening to this patient?"

I start asking:

"How does this fit the diagnosis I've already chosen?"

Those are very different approaches.

This is why the basic assessment framework remains so useful.

Airway.

Breathing.

Circulation.

Disability.

Exposure.

It gives you somewhere to start before you've worked everything out.

You don't need to know exactly what the diagnosis is before deciding that someone has a problem that needs your attention.

Sometimes you just need to recognise that something has changed.

This connects to something bigger

This is where prioritisation connects with something I've written about before.

Experienced emergency nurses aren't necessarily people who know the diagnosis faster.

Often, they're people who notice things differently.

They notice that the patient doesn't look quite right.

They notice that something doesn't fit.

They notice that the trajectory is changing.

They start thinking about what might happen next.

And then they have to decide where their attention is most useful.

That is what makes prioritisation much more than simply knowing ABCDE.

ABCDE gives you structure.

Experience helps you decide what deserves your attention within that structure.

And even experienced nurses get this wrong sometimes.

Because emergency nursing is messy.

You have incomplete information.

You have competing demands.

You have limited resources.

Sometimes you're making an educated guess.

The important thing is that you're prepared to change your mind when the information changes.

Priorities aren't permanent

One of the biggest differences between novice and experienced practice is understanding that prioritisation isn't something you do once at the beginning of the shift.

It happens constantly.

The patient who wasn't your priority ten minutes ago might suddenly become the most important patient in the department.

The patient you were worried about might improve.

The quiet patient might deteriorate.

The ambulance you've been expecting might arrive with someone much sicker than anticipated.

Your original plan might suddenly become irrelevant.

That's not necessarily failure.

That's emergency nursing.

The environment changes, so your priorities change with it.

The mental list in your head isn't really a queue.

It's more like a map that you're constantly redrawing.

The loudest person still matters

None of this means ignoring people because they aren't the sickest patient.

Pain matters.

Distress matters.

Anxiety matters.

A patient who is frightened or angry still deserves care and communication.

Sometimes dealing with a distressed or agitated patient is exactly the right thing to do because leaving them might create a much bigger problem.

The difference is understanding why you're doing it.

You aren't necessarily treating them because they're the highest clinical priority.

You might be dealing with them because you're preventing escalation, maintaining safety or removing a distraction that is consuming resources.

That's still good prioritisation.

The important thing is not to confuse demand with danger.

The skill isn't doing everything

Perhaps the biggest lesson I've learned about prioritisation is that you will never finish everything.

There will always be another phone call.

Another request.

Another task.

Another patient.

Another piece of paperwork.

Another thing that someone thinks needs to happen immediately.

You can't make all of that disappear.

What you can do is become better at deciding where your attention makes the biggest difference.

Sometimes that means saying:

"That can wait."

Sometimes it means saying:

"I can't do that right now."

And sometimes it means abandoning something you've already started because the situation has changed.

That can feel uncomfortable.

Especially when you're early in your career and feel like you should be able to complete everything you're given.

But emergency nursing isn't about completing the longest list.

It's about protecting the things that matter most.

So when everything feels urgent, take a moment.

Look beyond the noise.

Ask yourself:

What needs my attention now?

What can safely wait?

And perhaps the most important question:

What happens if I don't deal with this now?

You might not always get the answer perfectly right.

None of us do.

But learning to ask the question is part of learning to think like an emergency nurse.

Further Reading: Career Development For Nurses

Emergency Nursing for Nurses

Explore our guides for nurses:

Enjoyed this? Share it